Diabetes UK pregnant women with diabetes guideline

The management of pregnant women with diabetes

All women with pre-existing diabetes

Pre-pregnancy counselling should be offered to all women with diabetes at all possible times

Women on oral hypoglycaemic agents (apart from metformin) or whose HbA1c is above normal should be started on insulin before conception or in unplanned pregnancy as soon as pregnancy is confirmed – women with HbA1c>10% (86 mmol/mol) should be advised to avoid getting pregnant

A 5 mg dose of folic acid should be started (ideally 3 months) pre-conception and continued to 12 weeks gestation

Women should be given healthy eating advice that is in line with that given to all women with diabetes

As early as possible the woman with diabetes should be seen in a combined clinic by a team including an obstetrician with a special interest in diabetes and pregnancy, a physician, a specialist diabetes dietitian, a specialist diabetes nurse and a specialist midwife

the woman (and her partner) should be included as members of the team and given sufficient appropriate information to make choices about her care

all women diagnosed with pre-existing diabetes, or with gestational diabetes, should test glucose levels before breakfast and 1 hour after every meal during pregnancy

A woman on an established insulin regimen should be able to continue. Some medication should not be taken during pregnancy, so it may be necessary to change to an alternative

The risk of hypoglycaemia is increased, so those close to the woman with diabetes should be instructed in its recognition, management and treatment; partners should be supplied with and taught to use glucagon

Diabetic ketoacidosis (DKA) is particularly dangerous in pregnancy, so the woman should be prescribed and instructed in the use of ketone testing strips; the emphasis should be on prevention

If DKA is suspected the woman must be admitted to level 2 critical care

A detailed retinal examination should be performed on all patients during the first trimester and each trimester for those with retinopathy to detect and treat any accelerated retinopathy

An ultrasound measurement of the foetal crown-rump length should be made in the first trimester to confirm the duration of pregnancy

A detailed 'anomaly' ultrasound should be performed between 18 and 22 weeks and analysed by an experienced doctor

Foetal growth and amniotic fluid volume should be assessed every 4 weeks from 28 to 36 weeks

Foetal well-being should not be assessed before 38 weeks

If delivery is indicated at <36 weeks, corticosteroids should be administered to prevent neonatal respiratory distress syndome and additional insulin given to prevent severe maternal hyperglycaemia and ketoacidosis

If pregnancy continues beyond 38 weeks, the woman should be offered induction of labour or C-section if the healthcare team think it is the best option (this is to prevent stillbirth)

With good diabetes control, it may be possible to prolong pregnancy to 39 or 40 weeks to achieve a vaginal delivery

Postpartum:

most mothers will need advice about their pre-pregnancy dose of insulin

breastfeeding should be encouraged

women should be warned they are more susceptible to hypoglycaemia if breastfeeding; extra monitoring should be performed and extra carbohydrate taken to prevent this

if the baby’s blood glucose level, stays below 2?mmol/l for two consecutive tests of if s/he is not feeding properly, the baby may be fed through a tube, syringe, or drip

mothers should be seen 6 weeks postpartum by their GP or at a combined diabetes clinic

mothers should have the opportunity to be seen by a multidiciplinary team, and be offered contraceptive advice

Gestational diabetes

At the booking appointment screening for gestational diabetes will be made using risk factors

body mass index >30 kg/m2

previous macrosomic baby weighing 4.5 kg or more

previous gestational diabetes

first degree relative with diabetes

family origin with high prevalence of diabetes—South Asian, Black Caribbean, Middle Eastern

If any one factor is present, a 2 hour 75 g oral glucose tolerance test should be performed (OGTT)

Diagnosis should be made if fasting venous plasma glucose is >7.0 mmol/l or fasting venous plasma glucose is <7.0 mmol/l but venous plasma glucose is >7.8 mmol/l 2 hours after a 75 g glucose load

Glucose tolerance changes during pregnancy, so the gestation at which the diagnosis was made should be recorded; if made in the third trimester the clinician should be cautious about the clinical implications of impaired glucose tolerance

Obstetric management should be individualised; induction or C-section should be offered at 38 weeks gestation

Dietary and lifestyle advice should be provided for all women with GDM by a registered dietitian

the woman should be advised to choose, where possible, carbohydrate from low glycaemic index (GI) sources, lean proteins including oily fish, and a balance of poly- and monounsaturated fats

the diet should give adequate calories and nutrients to meet the needs of pregnancy and be consistent with the maternal blood glucose goals that have been established

appropriate exercise should be encouraged

Blood glucose should be self-monitored daily with frequency depending on treatment

Hypoglycaemic agents may include insulin or oral hypoglycaemic agents (metformin and glibenclamide)

If fasting glucose levels exceed 5.9 mmol/l or pregnancy progresses past term there should be increased obstetric surveillance because of the risk of stillbirth

Diabetes UK. Recommendations for the management of pregnant women with diabetes (including gestational diabetes). 2003, updated June 2010 First included: February 2002, Updated: February 2004, June 2004, Februay 2007, October 2007, June 2010.